Form F-05260 - Letter Of Non-Marriage Application - Wisconsin Department Of Health Services

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Clear / Reset Form

Division of Public Health

Wis. Stat. § 69.21

F-05260 (Rev. 05/2017)

Page 1 of 2

LETTER OF NON-MARRIAGE APPLICATION

Personally identifying information requested on this form, including credit card information and your signature, will be used to process your application and

payment for the requested copies.

 If you require proof that a Certificate of Marriage has NOT been filed with the Wisconsin State Vital Records Office, a search for a Certificate of

Marriage must be conducted for those years that you were a resident of Wisconsin from (1) the time you were 16 years of age until the present OR

from (2) the date your last marriage ended in annulment, divorce, or death.

 The Wisconsin State Vital Records Office provides a Letter of Non-Marriage solely as a requirement for marriage in another country.

 If you had two or more names during the period to be searched, you must indicate each name used and the years that each name was used.

 If no Certificate of Marriage can be found using the information from this application, you will receive a Letter of Non-Marriage as proof.

 If you are submitting this application by FAX, your credit card number and expiration date are required. The credit card number and expiration date will

only be used for payment for the fees specified in SECTION III – FEES below on this Letter of Non-Marriage Application.

PENALTIES:

Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more

than $10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. § 69.24(1)].

See page 2 of this form for valid photo ID requirements for processing this application.

SECTION I – SHIP TO INFORMATION (Print or type.) (You must complete this section for application to be processed.)

1. NAME – First

Middle

Last

2. DAYTIME TELEPHONE NUMBER

(

)

3. STREET ADDRESS or P.O. BOX (You must provide a street address if you are requesting shipping by UPS.)

APT. No.

4. CITY

5. STATE

6. ZIP CODE

7. EMAIL ADDRESS

SECTION II – APPLICANT’S RELATIONSHIP TO THE PERSON NAMED ON THE LETTER OF NON-MARRIAGE (CHECK ONE)

I am requesting a Letter of Non-Marriage for MYSELF.

I am a member of the immediate family of the person named in Section V.

Check one:

Parent

Child

Brother / Sister

Maternal Grandparent

Paternal Grandparent

I am a representative, authorized by any person indicated in one of the above checkboxes, including an attorney.

Specify the person you represent:

_________________________________________________________________________________________

I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies

of the requested Letter of Non-Marriage in accordance with the categories listed above.

SIGNATURE

Date Signed (MM/DD/YYYY)

(Applicant)



SECTION III – FEES

FEES ARE NOT REFUNDABLE.

CANCELLATIONS ARE NOT ACCEPTED.

Mandatory fees are already filled in. Please fill in additional fees for extra copies or UPS delivery, if applicable.

SEARCH FEE (includes one copy) ………………………………………….........………………………......…………..….

$ 20.00

20.00

$0.00

ADDITIONAL COPIES of the same letter issued at the same time as the first copy ____________________

$ 3.00

_________

Number of additional copies

$20.00

I AM MAILING IN THIS APPLICATION WITH A CHECK OR MONEY ORDER

TOTAL _________

(Make payable to: State of Wis. Vital Records. Mail to: State Vital Records Office, PO BOX 309, Madison, WI, 53701-0309)

------------- OR ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

I AM FAXING IN THIS APPLICATION WITH A CREDIT CARD NUMBER TO (608) 226-5460

(Fax fees are in addition to those listed above. Additional mandatory fax fees are already filled in.)

FAX EXPEDITED SERVICE FEE ……………….………...……………………………………….......……………….........…………… $ 20.00

20.00

FAX CREDIT CARD PROCESSING FEE ……...……………………………………………………………........……………………… $

6.00

$0.00

Regular Mail - No additional cost; mailed within five business days ………………………………….. .. .. .…… $

0.00

__________

SHIPPING

UPS Next Day - $19.00 in the continental U.S.A.; shipped within two business days ..................................... $ 19.00